Standard Birth Plan

PATIENT LABEL
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Comfort Measures/Pain Relief
You will receive ongoing support and encouragement throughout labor.
I would like to try the following coping strategies:
Walking
Position changes
Rocking chair
Birth ball
Bath/shower/whirlpool tub
Breathing & relaxation techniques
Massage
Other: _______________________________________________________
_______________________________________________________
_______________________________________________________
Pain Medication (during labor/delivery)
I plan to labor without the use of pain medication.
I will ask for pain medication if I need it.
I would like to have the nurse offer me pain medication.
If I ask for pain medication, I would like to consider using:
IV medication
an epidural
Progress of Labor
Rupture of Membranes
I would prefer to have my membranes rupture naturally, without intervention.
I think it is fine if my healthcare provider ruptures the membrane.
If labor is not progressing, I would like to try the following:
Walking with my support person
Rocking in the rocking chair
Rupture my bag of waters
Begin Pitocin (a medication used to stimulate contractions)
Pushing
When it is time to push, I’d like to:
push instinctively, in response to my body’s cues.
be coached on when to push and for how long (most common with an epidural).
I would like to use the following positions for pushing:
semi-reclining
side-lying
squatting
hands and knees
positions that are comfortable at the time
Warm compresses / perineal massage:
I would like warm compresses applied to the perineum while pushing.
I have been using perineal massage to prepare the perineum for birth.
Form# 10BIRTHPLAN Rev 9/10
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Standard Birth Plan PDF

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